CODING FOUNDATIONS COURSE
◉ Medical Necessity. Answer: A diagnosis that provides a valid
health care reason for services provided for a patient.
◉ Risk factor. Answer: A condition or illness that increases a
patient's susceptibility to a disease or condition.
◉ Sign. Answer: Evidence via a laboratory results, test results, x rays,
etc. of a disease or condition that a patient has.
◉ Symptom. Answer: An abnormal state or sensation that a patient
states they are experiencing.
◉ Supporting documentation. Answer: The data in a patient's chart
that supports the codes chosen.
◉ Complication. Answer: An unexpected condition that develops
after a surgery, procedure, test, or treatment while a patient is in the
hospital.
, ◉ Exacerbation. Answer: An increase in the severity of a condition
or illness that the patient already has.
◉ Adverse effect of. Answer: When a drug, medicine, or test material
causes a reaction in the patient.
◉ Sequela. Answer: A late effect of one condition or disease that
causes a second condition.
◉ NEC - Not Elsewhere Classified. Answer: Details in the
documentation that are not described in any other code in the code
book.
◉ NOS - Not Otherwise Specified. Answer: The absence of details in
the documentation that might be used to code more specifically.
◉ Other specified. Answer: Information that the physician has
documented but is not found in the code descriptions available.
◉ Etiology. Answer: A physician's study of and determination of the
cause of a disease or condition.
◉ Eponym. Answer: A condition or disease named after the person
who discovered it.